Together with hospitals in other European countries, Norwegian hospitals are helping Ukrainian patients and easing the pressure on the Ukrainian health service. The Norwegian health service and Armed Forces have a large learning potential in this area.
Norway has reason to be proud of its efforts in the medical evacuation of patients from Ukraine. For over a year, hospitals and healthcare personnel in Norway and the Norwegian Armed Forces Joint Medical Services have been working together on this with colleagues at home and abroad. They have learned a lot both organisationally and medically, have gained new experience in coordination between hospitals in Norway and have been able to test and develop civilian and military preparedness and transport systems. Health authorities throughout Europe have been closely involved in the international effort in civil preparedness.
After Russia's attack on Ukraine on 24 February 2022, many Ukrainian patients fled westward to other countries. They feared that they would not receive the medical treatment they needed as a result of the war. Most patients went to Poland, and it was mainly those with cancer, infections and chronic illnesses who left first. They also fled to countries such as Moldova, Slovakia and Romania.
The EU recognised that the number could increase considerably, and it was assumed that there would be a need to assist with the treatment of war casualties. A special medical evacuation scheme was quickly established within the framework of the European Union Civil Protection Mechanism (UCPM), which is the EU's body for international cooperation in civil preparedness. Although Norway is not a member of the EU, we are an active partner in the UCPM, with the Norwegian Directorate for Civil Protection as the Norwegian contact point (1) . Norway donates to and provides various types of assistance in civil and military preparedness as a result of the war in Ukraine, and medical evacuation forms part of this.
In March last year, the regional health authorities were commissioned by the Ministry of Health and Care Services to organise the medical evacuation of Ukrainian patients to Norway (2) . The coordinating function was to be managed by the South-Eastern Norway Regional Health Authority, and the National Coordination Centre for the Medical Evacuation of Ukrainian Patients was established at Oslo University Hospital. Meanwhile, the Norwegian Directorate of Health invoked the cooperation agreement with the Norwegian Armed Forces for assistance to transport sick and injured patients using the Norwegian Armed Forces' aircraft and personnel resources.
The coordination centre established contact with government agencies at home and abroad and devised a system for Norway to receive and assess requests for medical evacuation. In cases where Norway decides to offer assistance, the coordination centre identifies a treatment provider and conveys this information via the Norwegian Directorate for Civil Protection and the EU. Offers of assistance can be rejected or accepted, and when they are accepted, the coordination centre will arrange travel and arrival in Norway through contact with the police, immigration authorities and other actors. The Norwegian Directorate of Health and the coordination centre work together on organising transport, which in most cases is carried out in collaboration with the Norwegian Armed Forces. In addition, the coordination centre provides practical expertise for the hospitals that receive patients from Ukraine, and gives advice on how patients can return to their homeland.
They are mostly ordinary refugees who have been sick for some time or who fell ill after leaving Ukraine
It is important to clarify that most Ukrainian patients in Norway did not arrive as part of the medical evacuation scheme; they are mostly ordinary refugees who have been sick for some time or who fell ill after leaving Ukraine. The medical evacuation arrangement is a 'hospital-to-hospital scheme' in which patients are sent to Norway to receive treatment. When the patient is discharged from hospital, it is usually the primary care service, the local authorities and the Norwegian Directorate of Immigration that ensure that they receive the necessary further treatment and follow-up. Having said that, many of the Ukrainian patients choose to return home once the treatment is complete.
Medical evacuation to Norwegian hospitals
Medical evacuation to Norwegian hospitals
The first patients arrived in Norway on 21 March 2022, and in the year that followed, over 200 patients arrived through the scheme. All regions and almost all hospitals are involved in the work. Despite the backlog after the pandemic, the virus season in the winter of 2022/23 and the strained finances in the specialist health service, the hospitals have always found room for these patients. We have found a great willingness to contribute among the health authorities.
Norway is one of the countries that receives the most patients via the medical evacuation scheme (3) . Overall, Europe offers hospital treatment to far more patients than that requested by the Ukrainian authorities, and the patients who do not come to Norway are always offered treatment in other European countries.
Medically evacuated Ukrainian patients in Norwegian hospitals shall, as a general rule, have the same rights and be treated the same as other patients in Norway to the greatest degree possible. However, various challenges exist in relation to language, culture, expectations, finances, family situation, living situation and asylum status. Consequently, Norwegian hospitals have had a steep learning curve, and have had to work closely with both the National Police Immigration Service and the Norwegian Directorate of Immigration. Interpreting services have proven to be a crucial, but also limited, resource. The Norwegian Directorate of Immigration plays an important coordinating role for patients being discharged from hospital, and after some challenges at the start, the new procedures seem to be working well.
The Ukrainian patients
The Ukrainian patients
The patients sent to Norway are from all age groups. Cancer and injuries make up the largest diagnostic groups, but there are also patients with infections and other conditions. A common feature among all of these patients is the limited information that is available on their health when they arrive in Norway. Many, however, have documents in Ukrainian, Russian or English with them. Although many patients would normally have been given an initial appointment at an outpatient clinic, the National Coordination Centre for the Medical Evacuation of Ukrainian Patients has advised that patients should be admitted to hospital on arrival. In Ukraine, it is more common for patients to be hospitalised than be treated as an outpatient, and some patients react to being sent to a reception centre for asylum seekers after waiting for weeks and months to be treated at a hospital in Western Europe.
A common feature among all of these patients is the limited information that is available on their health when they arrive in Norway
Good planning is essential and sufficient time must be set aside prior to admission to obtain an overview of a patient's medical history and previous treatment. Patients must be screened for resistant microbes, and additional examinations are sometimes needed. When sufficient time is allocated, the medical practitioners, patients and their families are able to jointly decide on a treatment plan, and good communication between all parties facilitates the further course of treatment.
It is absolutely essential that an interpreter is present. Although there are good solutions for telephone interpreting, the physical presence of an interpreter is recommended upon arrival. This means that documents on the patient's health can be translated immediately, and it provides a better basis for reaching a shared understanding of the situation and what is needed. Feedback received by the coordination centre from patients, their families and the Ukrainian authorities suggests that there are challenges related to unmet needs for information and patient involvement, as well as misunderstandings due to language and culture.
Norwegian hospitals often use Russian or Ukrainian-speaking staff as interpreters. This is excellent for everyday conversations, but we encourage the use of professional interpreters for critical conversations. In some cases, patients and staff who act as interpreters develop close friendships and bonds, which complicates the interpreting work, and some patients have even said that they do not dare to talk openly and honestly with the practitioner because of their close relationship with the person acting as an interpreter.
Learning for the Norwegian health service
Learning for the Norwegian health service
The acceptance of patients from Ukraine, especially those with injuries and infectious diseases, has presented the Norwegian medical community with new challenges, and it has gained new insight and knowledge. We expect that these experiences will be written about and published by the medical community, and we will only give a brief description of the patient group here. Ukrainian colleagues and healthcare personnel are perceived to be adept in the initial treatment of injuries and in selecting which patients to send out of the country. The patients who can benefit most from the health care and rehabilitation offered or who represent the greatest burden to the Ukrainian health service are selected for medical evacuation. This means that it is often patients with complicated injuries who are proposed for medical evacuation.
The patients who can benefit most from the health care and rehabilitation offered or who represent the greatest burden to the Ukrainian health service are selected for medical evacuation
Open and infected wounds, lack of soft tissue coverage and resistance problems are common. These are patients who require extensive resources and specialist expertise, and who remain in isolation in hospital for several weeks. Interdisciplinary collaboration and repeated surgical interventions are often necessary. In addition, there is a need for psychosocial support, interpreting and social work services, nutritional physiology and rehabilitation. These patients may have medical problems that have not been seen for generations in Norway. When the first wave of Ukrainian war casualties arrived in June 2022, the resources needed were underestimated, and some departments were overburdened. We have all learned from this and we now believe we have found a better balance.
Transport is a bottleneck
Transport is a bottleneck
For many countries, patient transport is the bottleneck in the receipt of medically evacuated patients from Ukraine. In Norway, we have an excellent air ambulance service with highly competent staff. In addition, the Norwegian Armed Forces have their own resources and preparedness agreements with private companies for additional capacity and large-volume transport. The evacuation capacity must be sufficient for peacetime, as well as during crises and wars. With regard to medical evacuation during the ongoing war in Ukraine, Norway has followed the principle of the lowest effective level of care, and we have used both commercial aircraft with and without healthcare personnel, in addition to specialised air ambulances.
The Norwegian Directorate of Health is the coordination centre's most important operational partner for transport and point of contact with the Norwegian Armed Forces for the activation of their resources. Through the instructions to provide assistance, the Norwegian Directorate of Health can, in line with the national health preparedness plan, activate the Armed Forces for the evacuation of a large number of patients, including those requiring respiratory care and those who are still mobile, with both military and civil aircraft (4) . An agreement with Scandinavian Airlines System (SAS) provides for rapid conversion of ordinary scheduled aircraft into an advanced air ambulance. SAS operates and flies the aircraft, while the Armed Forces Joint Medical Services is responsible for the medical and operational aspects. The Armed Forces carry out ECMO transport in Norway several times a year via military aircraft and helicopters on behalf of the civilian health service, and have previously carried out several international operations with SAS aircraft. The collaboration with SAS is unique in a global context, and ensures a highly efficient use of resources. It brings together the business sector and civil and military authorities to provide critical capacity within emergency preparedness.
Most Ukrainian patients in the medical evacuation scheme are now transported by Norway, and the EU describes Norway as pivotal to this work
Since August 2022, Norway has worked on behalf of the EU to assist with the transport of more than 1200 patients and family members to various countries in Europe (5) . Most Ukrainian patients in the medical evacuation scheme are now transported by Norway, and the EU describes Norway as pivotal to this work. This international cooperation has also led to the Norwegian Armed Forces Joint Medical Services and air evacuation group gaining unique experience from more than 60 flight operations. The air evacuation group has formed affiliations with medical personnel from the civilian health service, giving this civil-military cooperation a new lease of life.
The Armed Forces' newly acquired experience with air evacuation was particularly valuable in Norway's efforts in the internal evacuation of patients in Turkey after the major earthquake in February this year. They were much better prepared and had experience that few if any other countries had (personal communication, Håkon Asak, medical officer in the Norwegian Air Forces Joint Medical Services). Consequently, Norway has been able to train and improve important national preparedness resources as we enter an era that will see an increasing focus on security and preparedness.
In the Norwegian transport effort, Norway has also provided experts to serve as MEDEVAC liaison officers in the EU's Emergency Response Coordination Centre (ERCC) in Brussels. The aim is to contribute to the coordination of transport within the EU and to establish useful international contacts in emergency preparedness. The experiences with the Norwegian model as described here, with cross-sector utilisation of resources and fruitful cooperation between private companies and public authorities and health services, are attracting attention in Europe. Look to Norway and its preparedness work is now a hot topic.